APPLICATION FOR AUTONOMOUS PRACTICE PSYCHOLOGICAL ASSOCIATES APPLYING FOR REGISTRATION AS PSYCHOLOGISTS

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1 T H E C O L L E G E O F P S Y C H O L O G I S T S O F O N T A R I O L'O R D R E D E S P S Y C H O L O G U E S D E L ' O N T A R I O 110 Eglinton Avenue West, Suite 500, Toronto, Ontario M4R 1A3 Tel (416) Fax (416) * Website: APPLICATION FOR AUTONOMOUS PRACTICE PSYCHOLOGICAL ASSOCIATES APPLYING FOR REGISTRATION AS PSYCHOLOGISTS This application can be filled out on your computer by typing in the spaces provided, printing the application out when completed, and mailing it to the College. Please be certain to include your application fee of $100. The Guidelines for Autonomous Practice Psychological Associates Applying for Registration as Psychologists provide greater detail about this process and may be found at in the Members section. March 2007

2 TABLE OF CONTENTS A PERSONAL IDENTIFICATION... 3 B EXAMINATIONS... 3 C DOCTORAL DEGREE... 5 D ACQUIRING POST DOCTORAL SUPERVISED PRACTICE... 5 E DOCTORAL COURSEWORK RECORDS... 7 Biological Bases of Behaviour... 8 Cognitive Affective Bases of Behaviour... 9 Social Bases of Behaviour Psychology of the Individual Ethics and Standards Assessment and Evaluation Intervention and Consultation Research History and Systems F DOCTORAL PRACTICA AND INTERNSHIPS G THE CONTROLLED ACT OF COMMUNICATING A DIAGNOSIS H DECLARATION OF GOOD CHARACTER I DECLARATION OF COMPETENCE J AUTHORIZATIONS K APPLICATION EXPIRY Psychologist PAGE 2

3 A PERSONAL IDENTIFICATION A1 Date of Application: A2 Surname: First Given Name: Autonomous Practice Certificate Number: B EXAMINATIONS B1 a) Have you written the Examination for Professional Practice in Psychology (EPPP)? b) If you have answered yes to question a) please indicate if your EPPP score was at least 500 or 70%. B2 a) Have you written the Jurisprudence & Ethics Examination (JEE)? b) If you have answered no to question a) please indicate if you had a specific jurisprudence and ethics evaluation as part of your oral examination with the College of Psychologists of Ontario. B3 In order to determine if an oral examination would be required of you, please answer the following questions: a) Are you proposing a change in your area(s) of practice? b) Do you currently have a term, condition or limitation on your certificate of registration as a psychological associate? If you have answered yes to question b) please list your term, condition or limitation: Psychologist PAGE 3

4 Date term, condition or limitation was imposed on the certificate: c) Are you presently subject to any disciplinary undertakings or agreements with the College? If you have answered yes to question c) please provide further details in the space below or attach additional information. By completing this application, you will be able to demonstrate how you intend to meet the nonexemptible registration requirements of Section 5.(1) 1. of Regulation 533/98, Registration. These requirements include: i. a doctoral degree from a program of study with content that is primarily psychological in nature as required in the guidelines published by the College; ii. a period of postdoctoral supervised practice. If your degree is from an institution outside Canada or the United States, you are asked to have it evaluated to determine if it is comparable in level to a recognized Canadian degree. You can arrange for this evaluation through the following service: World Education Services 45 Charles Street, Suite 700, Toronto, ON, M4Y 1S2 Tel: OR Comparative Education Services, University of Toronto 315 Bloor St. W., Toronto, Ontario, M5S 1A3 Tel: Fax: If your transcripts are in a language other than English or French, you must obtain an official translation. The College will accept translations done by an official translation agency or official notarized translations prepared in the country of origin. Psychologist PAGE 4

5 C1 University Title of Degree Awarded C Date of Award DOCTORAL DEGREE Section 5.(1) 1.i, Reg. 533/98 Program An official transcript of the doctoral degree must be sent by the university directly to the College. C2 Official title of the DEPARTMENT in which you were enrolled for degree(s): C3 Is your doctoral degree from a program that is CPA or APA accredited? C4 Title of doctoral thesis (or program equivalent of thesis): Supervisor: Reference, if published: D ACQUIRING POST DOCTORAL SUPERVISED PRACTICE If you: 1) are proposing no change in the area(s) of practice, client group(s) or activities for which you were previously registered for autonomous practice as a psychological associate; 2) have no terms, conditions or limitations on your certificate of registration as a psychological associate; and 3) are not presently subject to any disciplinary undertakings with the College, then please advise which option you are choosing in order to complete the required post doctoral supervised practice (Section 5.(1)1. ii, Regulation 533/98 I am: Requesting a certificate for Supervised Practice as a psychologist and am submitting signed Supervisors Agreement forms; OR Continuing to practise as a psychological associate while I accumulate the 1500 hours of post doctoral supervised practice. Please refer to the Registration Guidelines to see what documentation is required. Psychologist PAGE 5

6 If you: Are changing your area(s) of practice, clients or activities, have a term, condition or limitation, or a disciplinary undertaking or agreement, you must request a certificate for supervised practice: I am applying for a certificate for supervised practice and am submitting signed Supervisors Agreement forms. If you: Intend to hold a certificate for supervised practice and maintain a previously established private practice please describe how you will manage: Announcement of services: Advising clients of your supervised practice status: Signing of reports: Billing: This information will be referred to the Registration Committee for review. You must be able to demonstrate that your Primary Supervisor will be able to oversee all private practice activities. Psychologist PAGE 6

7 E DOCTORAL COURSEWORK RECORDS The College requires detailed descriptions of all the additional coursework in psychology you have completed since the time you initially applied for registration as a psychological associate. On the sheets marked E1 to E10, please enter the details requested. The College will use this information to confirm that you have: the required foundational knowledge; the professional practice knowledge for your declared area(s) of practice, activities and client populations; and the required knowledge for formulating and communicating psychological diagnoses. Psychologist PAGE 7

8 E1 FOUNDATIONAL KNOWLEDGE Biological Bases of Behaviour Includes such courses as: Physiological psychology, Comparative Psychology, Neuropsychology, Sensation & Perception, Psychopharmacology a. Course Title Institution Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 8

9 E2 FOUNDATIONAL KNOWLEDGE Cognitive Affective Bases of Behaviour Includes such courses as: Learning, Thinking, Motivation, Emotion, Cognition a. Course Title Institution Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 9

10 E3 FOUNDATIONAL KNOWLEDGE Social Bases of Behaviour Includes such courses as: Social Psychology, Group Processes, Organizations & Systems, Community Psychology, Environmental Psychology, Cultural Issues a. Course Title Institution Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 10

11 E4 FOUNDATIONAL KNOWLEDGE Psychology of the Individual Includes such courses as: Personality Theory, Human Development, Abnormal Psychology, Psychopathology, Individual Differences a. Course Title Institution Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 11

12 E5 PROFESSIONAL PRACTICE Ethics and Standards Includes such courses as: Seminars devoted to professional issues and relevant legislation, Professional Ethics a. Course Title Institution Course (as shown on Of credits: Of instruction: b. Course Title Institution Course (as shown on Of credits: Of instruction: c. Course Title Institution Course (as shown on Of credits: Of instruction: d. Course Title Institution Course (as shown on Psychologist PAGE 12

13 E6 PROFESSIONAL PRACTICE Assessment and Evaluation Includes such courses as: Psychological Assessment Techniques, Psychodiagnostic Assessment, Neuropsychological Assessment, Program Evaluation, Clinical Psychology, Personality Assessment a. Course Title Institution Course (as shown on Of credits: Of instruction: b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 13

14 E7 PROFESSIONAL PRACTICE Intervention and Consultation Includes such courses as: Psychotherapy, Counselling, Behaviour Modification, Intervention Techniques, Career Counselling, Psychological Consulting a. Course Title Institution Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Of credits: Of instruction: Psychologist PAGE 14

15 E8 PROFESSIONAL PRACTICE Research Includes such courses as: Research Design, Experimental Procedures, Laboratory Methods, Statistics, Multi-variate Analysis, Test Construction and Validation a. Course Title Institution Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 15

16 E9 PROFESSIONAL PRACTICE History and Systems Includes such courses as: History of Psychology, Historical Development of Professional Practice a. Course Title Institution Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 16

17 E10 Other psychology courses not covered in previous categories a. Course Title Institution Course (as shown on b. Course Title Institution Course (as shown on c. Course Title Institution Course (as shown on d. Course Title Institution Course (as shown on Psychologist PAGE 17

18 F DOCTORAL PRACTICA AND INTERNSHIPS Beginning with the most recent, give a complete record of your practica and internships. F1 Dates from: Title or position: Organization or institution name: General services offered by organization or institution: to: Practicum Internship Your duties: Type of client: Total Supervisor s name: Address: Professional affiliation: F2 Practicum Dates from: Title or position: Organization or institution name: to: Internship General services offered by organization or institution: Your duties: Type of client: Total Supervisor s name: Address: Professional affiliation: Psychologist PAGE 18

19 G THE CONTROLLED ACT OF COMMUNICATING A DIAGNOSIS Chapter 18, Section 27.(2) of the Regulated Health Professions Act states: (2) A controlled act is any one of the following done with respect to an individual: 1. Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely upon the diagnosis. Section 4. of the Psychology Act, 1991, states: In the course of engaging in the practice of psychology, a member is authorized, subject to the terms, conditions and limitations imposed on his or her certificate of registration, to communicate a diagnosis identifying, as the cause of a person s symptoms, a neuropsychological disorder or a psychologically based psychotic, neurotic or personality disorder. In addition to the foundational and professional practice knowledge required for a practice area, a member must have a specific set of knowledge, skills, and formal training in order to formulate and communicate a psychological diagnosis. For details, please refer to Appendix B of the Registration Guidelines. If your Declaration of Competence specifies solely the area of industrial/organizational psychology, you do not need to complete this section. If you declare other practice areas, you must complete this section. To demonstrate that you have the required knowledge base, please indicate which of your graduate courses has covered the following four required knowledge areas: Psychopathology Personality theory / individual differences Psychological assessment Psychodiagnostics An undergraduate course, while it informs the subsequent study, is not the equivalent of, or a substitute for, a graduate psychology course. You require the equivalent of a graduate half course (of approximately 36 hours duration) in each of the four knowledge areas. Although the subject may not be included in the course title, or the subject may be covered in more than one course, please use the boxes below to demonstrate as fully as possible that you have the necessary amount of graduate coursework coverage. If three boxes are not sufficient to list the necessary courses in each subject, please copy the page. Psychologist PAGE 19

20 G1 Psychopathology Course Title Course (as shown on Previously listed on application page # Course Title Course (as shown on Previously listed on application page # Course Title Course (as shown on Previously listed on application page # Brief description of course contents related to psychopathology: Brief description of course contents related to psychopathology: Brief description of course contents related to psychopathology: G2 Personality Theory / Individual Differences Course Title Course (as shown on Previously listed on application page # Course Title Course (as shown on Previously listed on application page # Course Title Course (as shown on Previously listed on application page # Brief description of course contents related to personality theory/individual differences: Brief description of course contents related to personality theory/individual differences: Brief description of course contents related to personality theory/individual differences: Psychologist PAGE 20

21 G3 Psychological Assessment Course Title Course (as shown on Previously listed on application page # Course Title Course (as shown on Previously listed on application page # Course Title Course (as shown on Previously listed on application page # Brief description of course contents related to psychological assessment: Brief description of course contents related to psychological assessment: Brief description of course contents related to psychological assessment: G4 Psychodiagnostics Course Title Course (as shown on Previously listed on application page # Course Title Course (as shown on Previously listed on application page # Course Title Course (as shown on Previously listed on application page # Brief description of course contents related to psychodiagnostics: Brief description of course contents related to psychodiagnostics: Brief description of course contents related to psychodiagnostics: Psychologist PAGE 21

22 Please indicate the formal training as described in Section F, in your graduate program that has provided you with the skills for formulating and communicating a diagnosis. This page is suitable for copying should you require more space to list practica or internships. G5 (Please indicate box number in this application where you initially described this training, e.g. F1) Dates from: Organization or institution name: to: Practicum Internship Describe the nature of the activities and supervision in this setting that contributed to the development of your skills for formulating and communicating a diagnosis: G6 (Please indicate box number in this application where you initially described this training, e.g. F1) Dates from: Organization or institution name: to: Practicum Internship Describe the nature of the activities and supervision in this setting that contributed to the development of your skills for formulating and communicating a diagnosis: Psychologist PAGE 22

23 H DECLARATION OF GOOD CHARACTER All applicants must answer the following questions. Their purpose is to enable the College to determine whether or not the applicant is of good character. A yes answer to any question or questions will not necessarily result in a refusal to register. Further details may, however, be requested from the applicant if any question is answered in the affirmative. The details supplied by the applicant will form part of the material to be reviewed before a decision on registration is made. I1 Have you ever been found to have committed professional malpractice by a court or tribunal? I2 Are you currently named as a defendant in any civil proceeding in which professional malpractice or negligence is alleged? I3 Are you currently the subject of any inquiry, investigation or proceeding in respect of allegations of professional misconduct, incompetence, fitness to practise or incapacity? I4 Have you ever been censured or reprimanded for sexual harassment or sexual misconduct? I5 Have you ever been found guilty of academic dishonesty by a post-secondary educational institution? I6 Have you ever been suspended or expelled from any post-secondary educational institution? I7 Are you now abusing, dependant on, or being treated for the abuse or dependence on alcohol or a drug? I8 Have you ever abused, been dependant on, or been treated for the abuse or dependence on alcohol or a drug? I9 Have you ever been denied or had any license, certificate, registration or permit revoked due to lack of good character? I10 Have you ever been suspended, disqualified, censured, or disciplined as a member of any professional organization? I11 Has there ever been a finding of contempt of court made against you, or have you ever been found to have contravened or failed to comply with any order of any Court? I12 Have you ever been found guilty of fraud or been found to have committed fraud? I13 Have you ever been found guilty of a criminal offence for which a pardon has not been granted or of an offence relevant to the practice of psychology, either within a Canadian jurisdiction or elsewhere? I14 Have you ever been dismissed from or asked to resign from any employment due to negligence, professional misconduct or academic dishonesty? I15 Is there any event, circumstance, condition or matter not disclosed in your replies to the preceding questions touching upon your conduct, character or fitness to practise that might be an impediment to your registration as a psychologist? Psychologist PAGE 23

24 I DECLARATION OF COMPETENCE Below, please indicate what you believe to be your principal area(s) of competence in the practice of psychology, and in which you will, through knowledge and formal training, be prepared to demonstrate competence prior to the award of a certificate of registration authorizing autonomous practice. You must be engaged in the identified practice area(s), activities and client groups during supervised practice. Assessment/Evaluation and Intervention/Consultation must be selected for each area chosen. Activities and Services Assessment / Evaluation Intervention/ Consultation Research Teaching Clinical Psychology Counselling Psychology School Psychology Area(s) Forensic/Correctional Psychology Clinical Neuropsychology Health Psychology Rehabilitation Psychology Industrial/Organizational Psychology Client group(s): Children Adolescents Adults Couples Families Seniors Organizations Explanatory note (optional): Name (please print): Date: Signature: Psychologist PAGE 24

25 J AUTHORIZATIONS K1 I authorize the College of Psychologists of Ontario to collect and maintain information from persons named in this application and from other persons or institutions as the College of Psychologists of Ontario in its discretion deems advisable in order to determine my eligibility for registration as a psychologist in the province of Ontario. I agree to save harmless all officers, directors, employees, servants and agents of the College of Psychologists of Ontario and those granting information regarding my application for registration at the request of the College of Psychologists of Ontario and hereby consent to the requesting and granting of any and all such information. I also authorize and consent to the release of any information obtained by the College of Psychologists of Ontario in the course of reviewing my application for registration at the request of any other professional body to whom I make application for registration, certification or licensing. K2 I certify that the statements made by me in this application are true, complete, and correct. I understand that a false statement may disqualify me from registration or be cause for revocation of any registration which may have been granted to me. K3 I have read the Registration Guidelines to assist my understanding of the requirements for registration as a psychologist. Signed: Date: K APPLICATION EXPIRY The College collects and uses the information in this application to assess whether you qualify to be issued with a certificate for practice as a psychologist in Ontario. The College discloses information only as permitted by Section 36 of the Regulated Health Professions Act, or as required by law. Psychologist PAGE 25

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